GENDER AND THE RIGHT TO REPRODUCTIVE HEALTH

GENDER AND THE RIGHT TO REPRODUCTIVE HEALTH 1st April , 2008 Health and Human Rights Workshop Programme Presentation, Nairobi, Kenya Claris Ogangah – FIDA Kenya

EXECUTIVE SUMMARY • Healthcare of the family depends on the women . • It is women who mostly use contraceptives, get pregnant, give birth, take care of the children, take care of the sick children and generally concern themselves with issues of health. • Therefore the standards and quality of health care affect and impact either negatively or positively on the lives of women. • Reproductive health care is very critical to women and it is therefore important to analyze whether and how health institutions reinforce gender inequalities by acts of omission or commission.

INTRODUCTION AND BACKGROUND Mainstreaming gender equality in institutions will:- • Improve the quality of Reproductive health services • Effectively meet the needs of reproductive health service seekers. • Make the services sustainable • Empower and inform the seekers of these services. • Improve communications between sexual partners, • Improve utilization of services. • Improve use of contraceptives • Reduce HIV transmission.

DEFINITION OF GENDER Gender is the economic social and cultural attributes and opportunities associated with being male or female in a particular setting at a particular point in time. • Gender equality means equal treatment of women and men in laws and policies, and equal access to resources and services within the society. • Gender equity means fairness and justice in the distribution of benefits and responsibilities between women and men. This often requires specific programmes and policies to end existing inequalities. • Gender discrimination means any distinction, exclusion or restriction made on the basis of socially, constructed gender roles and norms which prevent a person from enjoying full human rights. • Gender integration means taking into account both the differences and the inequalities between men and women in service provision.

REPRODUCTIVE HEALTH Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all the matters relating to the reproductive system and to its functions and processes. Reproductive health includes but is not limited to the following:- • pregnancy • maternal mortality and morbidity • contraceptives • abortion • HIV/AIDS • Violence Against Women • Sexually Transmitted Infections • Cancer

REPRODUCTIVE RIGHTS • Reproductive rights embrace certain human rights that are already recognised in national, regional and international human rights documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly on the number ,spacing and timing of their children and to have information and means to do so, and the right to attain the highest standard of sexual and reproductive health. • This includes the right to make decisions concerning reproduction free of discrimination, coercion and violence as expressed in the human rights documents.

LINK BETWEEN GENDER AND REPRODUCTIVE RIGHTS Gender influences health and reproductive health specifically in the following ways:- • -Exposure, risk or vulnerability. • -Nature severity and frequency of health problems • -Ways in which symptoms are perceived • -Health seeking behaviors • -Access to health services • -Ability to follow advised treatment • -Long term social and health consequences

LINK BETWEEN GENDER AND REPRODUCTIVE RIGHTS Gender based differences in access to and control over resources in power and decision making and in roles and responsibilities have implications for women’s and men’s health status. They result in:- • Differential risks and vulnerability to infections and health conditions. • Different perceptions of health needs and appropriate forms of treatment. • Differential access to health services • Different consequences or outcomes from disease • Differing social consequences as a result of ill health The main reason for linking gender and reproductive health therefore is to increase the number of health providers, planners, policy makers and trainers who understand a gender and rights perspective on health and who have analytical tools to help implement gender and rights –sensitive reproductive health policies and programmes.

LINK BETWEEN GENDER AND REPRODUCTIVE RIGHTS The gender approach to reproductive health:- • Gives high priority to quality of care in its many dimensions • Pays attention to the needs of everyone in the society (married women, unmarried women, adolescents, men and older people.) • Aims at the provision of integrated reproductive health services • Promotes the right to choice and aims to create conditions that would enable choice. • Encourages male participation in family planning and in women’s health • Gives me and women a greater choice on reproduction

INTERNATIONAL HUMAN RIGHTS IN RELATION TO REPRODUCTIVE HEALTH Human rights are primarily about the relationship between the individual and the state. States have three obligations to their citizens these are:- • Obligation to respect: - This means that the state cannot violate the rights of an individual. A government can be deemed to violate the responsibility to respect the right to health if it withholds such services. • Obligation to protect: - This means that the state has to prevent violations of rights by non state actors. This is why laws are made to make some acts illegal. • Obligation to fulfill: - This means that States have to take all appropriate measures, be it legislative, administrative, budgetary or judicial towards the fulfillment of a right. A state can be found to be in violation of the right to health if it fails to allocate sufficient resources to meet a certain health demand. International human rights law defines what Governments can do to us, cannot do to us and should do to us and consists of the obligations that governments have agreed on in order to be effective in promoting and protecting the rights of individuals.

INTERNATIONAL HUMAN RIGHTS IN RELATION TO REPRODUCTIVE HEALTH Some of the rights include • RIGHT TO LIFE: - This was traditionally understood to relate to freedom from arbitrary deprivation of life. But now it includes the positive obligation for the state in relation to maternal mortality. • RIGHT TO BODILY INTERGRITY AND SECURITY OF PERSON:- This includes security from sexual violence and assault and in relation to reproductive health includes programmes that compel sterilization and abortion or those that prohibit women from receiving family planning services • RIGHT TO PRIVACY; - Includes protection in relation to sexuality. • RIGHT TO BENEFIT FROM SCIENTIFIC PROGRESS: - Includes recognition that a woman’s right to control her own reproduction would be enhanced by for example microbicides. • RIGHT TO SEEK, RECEIVE AND IMPART INFORMATION:-Includes making a woman make fully informed choices.

INTERNATIONAL HUMAN RIGHTS IN RELATION TO REPRODUCTIVE HEALTH • RIGHT TO EDUCATION:- • RIGHT TO HEALTH:- • RIGHT TO EQUALITY IN MARRIAGE AND DIVORCE • NON DISCRIMIMATION:- Though the legal obligation for implementing human rights is focused on governments all other actors have responsibilities for promoting such rights for example in the health care sector such actors include hospitals both public and private, individual health care providers, corporations e.t.c.

International and regional human rights standards and the Constitution require Kenya to: • Eliminate discrimination in health care facilities • Eliminate all other barriers that women face in accessing health care services • Prevent abuse and neglect of women in health care facilities • Abolish user fees that contribute to differences in health care services and inhibit access to services • Prevent abusive treatment in health care facilities • Prevent detention in health facilities • Enable women to seek redress for rights violations • Provide sufficient family planning information • Follow informed-consent procedures • Ensure transparent record-keeping • Treat patients with respect and with confidentiality • Provide patients with access to their files • Follow informed-consent procedures • Prevent detention in health facilities, which separate patients from their families

Ministry of Health Maternal Care Standards • Indicate the quality of services that health care providers should provide for patients and their babies. • Specify that the right to dignity, privacy and confidentiality and right to information of patients should be respected. • Call for every pregnant woman seeking care to be attended to by a skilled healthcare provider within 30 minutes of arriving at a facility. • Patients should be allowed to be accompanied by a companion during delivery and even before or after delivery at the clinic. • Emphasize the importance of having a “clear and comprehensive obstetric medical record” for patients. • Outline the resources that health care facilities should have for achieving each of these goals.

FIDA KENYA’S EXPERIENCES WITH REPRODUCTIVE HEALTH AND RIGHTS FAILURE TO DELIVER REPORT Our main findings focused on several key issues: • Abuse and neglect before, during, and after delivery which included: • Physical and verbal abuse—being pinched, slapped, beaten, being called “stupid”, “psycho”, told to “just die”’ being cut with scissors to make delivery easier for the nurses; forcible FGM • Neglect—being left to deliver alone or assisted by another patient • Violations around stitching after delivery • Having to wait extended periods of time for stitching after delivery • Being stitched with insufficient or no anesthesia • Poor Quality of Care • Understaffing • Not receiving care/no assistance walking to/from delivery room or getting on bed • Lack of supplies/facilities • No gloves, cotton wool, anesthesia • No beds/linens • Nothing to wrap baby in

FIDA KENYA’S EXPERIENCES WITH REPRODUCTIVE HEALTH AND RIGHTS • Contraceptive Access • User fees preventing access to family planning even though it is supposed to be free in government facilities and where the government has provided it for free to private facilities • Contraceptive stock outs which prevent reliable access to preferred form of contraception/lack of necessary equipment –for example, no gloves to insert IUD • Women visiting facilities run by FBOs do not have access to all forms of contraception • In Catholic facilities, only natural family planning • No Christian-run facilities provide EC although they treat sexual violence victims • Violations of informed consent around tubal ligation • Government stats indicate that more than 8% of women who had been sterilized did not understand it was a permanent method

FIDA KENYA’S EXPERIENCES WITH REPRODUCTIVE HEALTH AND RIGHTS • Discrimination in services because of inability to pay • User fees preventing people from seeking certain kinds of services like reproductive health check-ups • Inconsistent and ineffective implementation of exemptions for services • Degrading and lengthy waiver process (where fee is supposed to be waived because of financial need) • Detention in health facilities for inability to pay (in both public and private facilities) • Women who have just delivered being kicked out of bed and forced to sleep on the floor • Having trouble getting food • Being verbally abused • Differences in care between public and private facilities • Congestion/long waits • Poor quality treatment • Having to bring your own supplies • Inappropriately levied costs/corruption

FIDA KENYA’S EXPERIENCES WITH REPRODUCTIVE HEALTH AND RIGHTS • Problems Complaining and Seeking Redress • Lack of information about patients’ rights • Not knowing one can complain • Lack of outlined procedures • Difficulties determining where one can complain or how to complain • Slow or no responses to complaints • Difficult getting information from government bodies • No freedom of information act although one has been drafted • Impact of restrictive abortion law • Stigmatization of PAC • Fear of prosecution • Violations of confidentiality/denial of services • Police asking for bribes not to report women • Issues for providers

RECOMMENDATIONS FROM THE RESEARCH • Protect patients’ rights • Develop and disseminating a patients’ bill of rights • Develop a public health campaign and comprehensive training program of health care providers focusing on patients’ rights and the importance of treating women in delivery and all patients with respect • Develop clear complaint mechanisms for both public and private hospitals • Acknowledge and outlaw the practice of detaining patients for inability to pay • Train health care providers on informed consent principles • Reform the existing payment system • Eliminate maternal health fees • Develop a clear and transparent waiver and exemption system that is implemented consistently in facilities throughout the country

RECOMMENDATIONS FROM THE RESEARCH • Ensure consistent contraceptive access • Have all health facilities regardless of religious affiliation provide EC to sexual violence victims • Address contraceptive supply issues • Develop a clear referral policy for all facilities and ensure that all health facilities abide by it so that women have access to comprehensive family planning information and services

ADVOCACY STRATEGIES • FIDA has developed a bill - REPRODUCTIVE HEALTH AND RIGHTS BILL which if enacted will govern issues of reproductive health. The bill is still in the validation stage and is yet to be forwarded to the Attorney General. • FIDA is currently developing a Patient’s Bill of Rights, which they hope will be adopted. Currently in Kenya, patients approach health care as if asking for a favor, rather than demanding a right. FIDA hopes that introducing a Patient’s Bill of Rights will help to change this attitude and increase health-seeking behavior. • FIDA also hopes to undertake a nationwide health campaign to educate women and other patients about their rights within the health system. • Currently, FIDA trains members of the police force on women’s human rights, and hopes to expand this training to health professional associations • FIDA hopes to integrate women’s human rights into continuing professional development for health workers. • FIDA is advocating for the development of an internal complaint mechanism at the Attorney General’s office, to address issues regarding the licensing of health professionals.

ADVOCACY STRATEGIES • FIDA also wants to create and publicize guidelines of what is free with regard to maternity services in Kenya. The Ministry of Health must develop clear guidelines regarding the cost of services and supplies at public health facilities. • FIDA plans to advocate faith-based organizations, including the Christian Health Association of Kenya (CHAK) to ensure that faith-based facilities which do not provide contraceptives are required to provide referrals to facilities that do provide contraceptives. • FIDA has already approached the Nursing Council, which has been very receptive to trainings on women’s human rights, and wants to make these trainings part of requirements for licensing. However, FIDA has yet to engage the National Nursing Association of Kenya (NNAK), which they hope to do in the upcoming months, noting that the demoralization of nurses and patients has a devastating impact on patient’s rights. • FIDA also plans to partner with groups advocating for an increase in funding to the health sector, to address the major issue of understaffing. • FIDA has been writing shadow letters to human rights committees and the Special Rapporteur on the Right to Health this is so that recommendations can be made to the Government on how to improve the sector

RESULTS FROM INTERVENTIONS • The government removed user fee for maternity services in all public health institutions. • The Government appointed a new person to head Pumwani maternity hospital and the new person is someone Fida has worked with on the report and is part of the RHRA and Fida hopes that this will translate in addressing the human rights violations that have been taking place in Pumwani. • Fida Kenya received an invite from the mid wives association to train them in rights based approach to service provision. • The office of the Director of Public Prosecution has indicated that it will assist Fida prosecute cases involving abuses in health facilities.

Recommendations to Government • Strengthen structures to protect patients’ rights • Public awareness programs to educate patients on their rights • Require health care facilities to establish formalized complaint mechanisms as part of licensing requirements • Strengthen complaint mechanism at Medical Board, councils • Provide information to judges and legal professionals on rights violations in health care context

To all health care facilities • Protect patients’ rights and promote accountability – • Training for staff on rights and dignity of patients • Complaint mechanisms • Have staff wear name badges • Fair and transparent payment policies

To Health Care Associations • Review ethical codes to provide sanctions for violations and publicize these provisions • Emphasize importance of patients’ rights in training and other member activities

Thank you! Asante sana!

GENDER AND THE RIGHT TO REPRODUCTIVE HEALTH